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Home My WebLink About0095 DONEGAL CIRCLE - Health 95 Donegal Circle , A = 169-030 Centerville 1 No. 42101/3 ORA ESSELTE 10% o Alr)` o-030 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 95 Donegal Circle Property Address Paula Yetman Owner Owner's Name / information is required for every Centerville Ma 02632 4/8/2015 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information t� � 3 on the computer, I� D`J' use only the tab 1. Inspector: �—+-- key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection Company Name 74 Beldan Ln. Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com SI4522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 7=rs--7- 4/8/2015 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection.does not address how the system ill pert in the future under the same or different conditions of use. 1n t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts w v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 95 Donegal Circle Property Address Paula Yetman Owner Owner's Name information is required for every Centerville Ma 02632 4/8/2015 page. CityTrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 95 Donegal Cir Centerville is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and a precast leach pit. The system was found to be in proper working condition at the time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 95 Donegal Circle Property Address Paula Yetman Owner Owner's Name information is required for every Centerville Ma 02632 4/8/2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 95 Donegal Circle Property Address Paula Yetman Owner Owner's Name information is required for every Centerville Ma 02632 4/8/2015 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 95 Donegal Circle Property Address Paula Yetman Owner Owner's Name information is required for every Centerville Ma 02632 4/8/2015 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 95 Donegal Circle Property Address Paula Yetman Owner Owner's Name information is required for every Centerville Ma 02632 4/8/2015 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Donegal Circle Property Address Paula Yetman Owner Owner's Name information is required for every Centerville Ma 02632 4/8/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 95 Donegal Circle Property Address Paula Yetman Owner Owner's Name information is Centerville Ma 02632 4/8/2015 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 95 Donegal Circle Property Address Paula Yetman Owner Owner's Name information is required for every Centerville Ma 02632 4/8/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: original , 1991 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 30"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: 20"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: 6" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 95 Donegal Circle Property Address Paula Yetman Owner Owner's Name information is required for every Centerville Ma 02632 4/8/2015 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 3" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers, took measurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 95 Donegal Circle Property Address Paula Yetman Owner Owner's Name information is required for every Centerville Ma 02632 4/8/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 95 Donegal Circle Property Address Paula Yetman Owner Owner's Name information is required for every Centerville Ma 02632 4/8/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was in good condition, no rot, water level was even with outlet invert. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): "If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 95 Donegal Circle Property Address Paula Yetman Owner Owner's Name information is required for every Centerville Ma 02632 4/8/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit had T of available leaching with a stain line 1' higher indicating no previous hydraulic overloading. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 95 Donegal Circle Property Address Paula Yetman Owner Owner's Name information is required for every Centerville Ma 02632 4/8/2015 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 95 Donegal Circle Property Address Paula Yetman Owner Owner's Name information is required for every Centerville Ma 02632 4/8/2015 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately v�2- i n 'T4N Z [7 A-2 3`1 i3-2 ZS'L, k0 A-3 38'(. o 3 � PIT `/? t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 95 Donegal Circle Property Address Paula Yetman Owner Owner's Name information is required for every Centerville Ma 02632 4/8/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 95 Donegal Circle Property Address Paula Yetman Owner Owner's Name information is required for every Centerville Ma 02632 4/8/2015 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 No.._.��. .... d /4.0......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ------. T("-.4............OF........?Aj2 45r.-,� ------------------------------------ , ppliration for Disposal Works Tnnstrurtiun Vrrmit Appl' tion is hereby made for a Permit to Construct ( �or Repair ( ) an Individual Sewage Disposal t ay ..... .............................. ------- -r -...!Z_..__ ......... o ation Addres o Lot No. YS Ibc �2_ '2....•...�-0.................... ...............0 X .E.---. . 11 gA._✓/�C `....... �....� /C K( &ner (L C address ..................................... ...•-•-'-------------•-•------•-....---•-----.............----........._......_................--- Installer Address UType of Building Size Lot.......151102...Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) pa., Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 104 Other fixtures ----•-----•-------------•--••----- -•---- W Design Flow.................��------........----gallons per person per day. Total daily flow................ -3�--��'---.._gallons. WSeptic Tank—Liquid capacity.16 gallons Length................ Width...__........... Diameter................ Depth_.._._.......... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area..... sq. ft. Seepage Pit No-------------I------- Diameter---------b...... Depth below inlet.._....4-..... Total leaching area.. 3___sq. ft. Z Other Distribution box ( Dosing tank ( ) '~ Percolation Test Results Performed by.._71514- .......�1_9'7....................... Date_._..._...4..(4-.(.qi......_.. a — a Test Pit No. 1....Z....minutes per inch Depth of Test Pit---_____-t.-L-... Depth to ground water........................ (z, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ------•------------------------------f--- O Description of Soil -` "' ............. �iJJ�S�-1........- - - - ------ - w �. - 1 ° -----•--------------'------........................................ ------------------------------------------------------------------------------------------------------------------------------------- -'----------------------......................................... U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ------------------------------------------------------------------------------------•-......----------------------------------------•------------------•------------------------•--------•----••......_. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Cj e as been issued y the board of health. uu Sign ................ ... .... ........................................................... ........l..r��..�-g Date Application Approved B _ c pP PP Y ... - ------- .. --- ... Application Disapproved for the following reasons: .. ----. ................................................................ ...... ............ .... . ............ . .. ............................... .. .. . .............----...---....--. ..--...----..........--------..................---------......... .......--------- --------------..............-.-...--.. Uare Permit No. ---------lyz Issued Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................1.OWWA............OF......... Af.2.05TA..................................................... Appliration for Disposal Works Tonotrurfion rantit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: 1 s Locagion .Addres - oI: Lot �No. � ..o. l`F '' .fd. ... ._._....f� J..• -�--.---....5 _/�._d.1r .�/<....,..d�........-- r r............................................. Owner Address a ....................... .{ �...... ......•.... ........... ....-..................................4.................................................... Installer Address Type of Building Size Lot_._.__-_•-._�,t__._.__??___Sq. feet U Dwelling—No. of Bedrooms.....................:......................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtur W Design Flow...............___��..�...._.........___..gallons per person per day. Total daily flow___..._......_.__......_.. ............. WSeptic Tank—Liquid capacityl(AD. .gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area.... ...........sq. ft. Seepage Pit No.............1------ ameter........ ...... Depth below inlet....... '...... Total leaching area._ 0...sq. ft. Z Other Distribution box ( Dosing tank ) Percolation Test Results Performed b .-_ 1 `��*__ "_... "_ ( ....._.. Y �---------------------------- Date.-----------•-----=---------�. ,al Test Pit No. I.....'"'�----minutes per inch Depth of Test Pit--------- .l.._ Depth to ground water........ .._._... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ------------------------------------------- , O Description of Soil----•--------------------0r••--_ •7.. -----•- !a. _ - -------------•-----------------------------------•---•--__... x �/ Vl:+^-'`- r. 1 ud -•-._• ' -----•--------__•__-•-•--------------------------•-------_____-•••--•- W ...........................•...........--------•---...•................_............._.............-•.........•-----.........--...••..........................•......................•..•--••-•••--••.. U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ----------------------------•----------------------------------•--•---------------------•----•......•--••....•••••••••-------•••-•---•-•---•••••---••-••-•••---•-•••••••---••••-•••••-••.._......_••---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compli ce.has been issued by the board of health. 91 Signed ...................... ..... ........................- ..................... ...... Date Application Approved By --------pef:rnlow e^ ----------------------------------------------------------------------------- Application Disapproved for tng reasons: ............. .......... . ... .................................................................................... Permit No. - Date....-....-. .�,.��.......................... Issued Date THE COMMONWEALTH OF MASSACHUSETTS �--- BOARgOF HEALTH _.. ..... - C�er#tfira t# of CITompita nre I§JS TO CERTIFY That the Individual Sewage Disposal System constructed ( Y,, ) or Repaired ( ) b .......... Y tillil...c. .." - y(� /') /[ Installer at �. �. } F i✓ 4JiV ✓f�. rw• .�h ................. ....... .....N_/ ................... . --� .......... .. ........ .. .... .............. ................................... has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ........ .//---......``. ......... tted ............................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE'CONSTRtJD AS AUARAN� EyTHAT THE t SYSTEM WILL FUNCTIONSAT XSFACTORY. 4 DATE...... ...-...----— 7 ----------------------------------- Inspector .................. ...... THE COMMONWEALTH OF MASSACHUSETTS --�•-^�" BOARD OF HEALTH "°w C !!L ...........�..0.(?� .............OF......... �.f�� +- t.-i. NoX1:.,L.-lb... FEE/0. ........... Dioposgl. Marko Tono#rndion rrntit Permission is hereby granted_..__ ':.'^f._...: �-_ 1 't"`.. (-- Permission -- to Construct ( � or R pair ( ) an IndividuaSewage Disposal System at No.../ _._ «?d�✓ ........ ••-••••. •--•-........ ._••-•••-_.... .--- ------•-••-•--•---•-•-•--••••-••----.....--•--•---•••--••-•••-••-•••-•-•.........._ Street as shown on the application for Disposal Works Construction Permit N =_ _____ ) .................` _._ ............. ------•---•-•-•---••••••-•-•.• ---------•-•-•-------•-----••• ...._._.. .. oard of Health DATE.......... '-°�•-•---•--- ... '�------------------------- - FORM 1255 HOSES & WARREN, INC., PUBLISHERS UatGtz1ro ; M t - r� ;= t tb_ 44-1- I- f �} f T 'GpL t o00 Ics.l\ !B�TY r.O rvl -•Atz EA t.-, c=p� 6T=: .. � 1 /�/ `, � f�TO L. i LOTA l_ D,dt 2GblQTI6U QAT S1u 02SS ER SULLIVAIV D 10..29733 Tap o` QJ � � I ol _ ' .!_� � A � I � _ � ry/ �•M. ��.� lay _IoQ .rar, Gg /4 lot �L�I to� t •�'G.=.1o2 - , . �=�'S � 1 ToP FND t Ia s Lo XVA DfS f 01.O L� ' SVT3SDf(. �PP�� f 2 f "Box I ov,4 '.. c E�7-K _ 1INV. p r LAN /V1 -, r r- .SIN ; � W�ru! - � � �•� } _ WASHED ` :� ! «•' 1 r i. E[ZTtFtED PLo-r Iz� LaG�.Tlo� tf�TEZVILLZ= � o Sc n;L� T;J. ,mot �Ft' L-•t�i,I :,Ceti (�L� 2L—i=`i=2c►"lca � ut� %�C�-L,�,cIG SZEgUtREMc�.tTy p� T14- Lv"i 1'L MTA!31lS. AN C7 SNor' :r 1=LOCV PLA,IQ t l �J v'r" 'Aprl I ,T REGIS'tttZ�D t-1 l;S` C7:i;A ti-1' 1� t,_I OT 11?�A�>C'O ' _ 1-A r(�L'J:nC'_lJi ScJ ♦/E`S' '(1lL- c:Fc�S T"�, 51�G,1:1t� 05TE2V L1...C_ U� t_L, 1Lt,�trl1►lL: l_oT l_lNa� ILPF�I_IC�A.I�IT ,J A/ CommOtlweaM Of Mossoc )Usetts John Grad 'f ^EXecLAW9 Office Of ENrOrTm ttOl Affairs D.E.P. Title V Septic Inspector_ D8p�11"te:1�f o��_ _ P.O. Box 2119 Teaticket MA 02536 i - Envieone�enta] P�rot��t�on _ (50 64-6813 112(. ,1 SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FO CEIVE® PART A _... - CERTIFICATION w AU `L � 1996. � Property Address: 95 Donegal Circle,Centerville Address of Owner: Date of inspection:8122196 (if different) Name of Inspector:John Graci JEJ Reality-Trust Company Name,Address and Telephone Number:- 9 - CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X Passes _ Conditionall Pas AS _ Needs Fu er luation By the Local Approving Authority Fails Inspector's Signature: Date: 8122196 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B.C, or D: A] SYSTEM PASSES: X I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: _One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y, N.or ND). Describe basis of determination in ail instances. If "not determined",explain why not.) The septic tank is metal, cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11115195) One Winter Street .• Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 1' s - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - -PART A -CERTIFICATION (continued) Property Address: _95 Donegal circle,Centerville Owner: JEJ Reality Trust _ - Date of Inspection:8122198 _ - Sewage backup or breakout or high static water level observed in the distribution box is due to a broken, settled or uneven distribution box.. The systemwllLpass inspection if(with approval of the Board of Health): - broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced. _The system required-pumping more than four times_a year due to broken or obstructed pipe(s). The — system will pass inspection if(with approval of the Board of Health): _ - broken pipe(s)-are replaced obstruction is-removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to.determine if the system is failing to protect the public health, safety and the environment. 1} SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING.IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm. 3) OTHER D] SYSTEM FAILS: _ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged t s cesspool. SAS is in hydraulic failure. (revised 11115195) 2 SUBSURFACE SEWAGE:DISPOSAL SYSTEM INSPECTION FORM -- PART A - - CERTIFICATION (continued) Property Address: 95 Donegal Circle,Centerville _ Owner:- _-JEJ Reality Trust _ Date of Inspection: 12219ti - D] SYSTEM FAILS(continued) _— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a-surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50.feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable; attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply _ the system is within.200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area (IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11115195) 3" Q -SUBSURFACE.-SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART B - CHECLIST. P ro pe rty Ad d ress: 95Donegal circle,Centerville - Owner: JEJ Reality Trust Date of Inspection.8122196 Check if the following have been done: _ _x Pumping information was requested of the owner, occupant, and Board of Health. X- None of the system components have been pumped for at least two weeks and the-and the system has been receiving normal flow rates during that period. Large volumes.of water have not been introduced into the system recently or as part of this inspection. . nla As buiIt.plans have been obtained and examined. Note if they are not available with NIA. X The facility or dwelling was inspected for signs of sewage back-up. x The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components,excluding the Soil Absorption System, have been located on the site. X The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions; depth of liquid, depth of sludge, depth of scum. X The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. X The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11115195) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -PART C - SYSTEM INFORMATION Property Address: 95 Donegal Circle,Centerville Owner: JEJ Reality Trust Date of Inspection:8122/96 _ - FLOW CONDITIONS _ _ - RESIDENTIAL: Design flow: 330 gallons Number of bedrooms: 3 -Number of current residents: 3 Garbage grinder(yes or no): No - Laundry connected to system(yes or no): Yes - - Seasonal use(yes or no): No -Water meter readings, if available: n/a - Last date of.occupancy: n1a - COMMERCIAL/INDUSTRIAL: Type of establishment: nfa Design flow:0 gallons/day Grease trap present: (yes or no) No Industrial Waste Holding Tank present: (yes or no) No Non-sanitary waste discharged to the Title 5 system: (yes or no) No Water meter readings,if available: n1a Last date of occupancy: n1a OTHER: (Describe) nla Last date of occupancy:. GENERAL INFORMATION PUMPING RECORDS and source of information: System has not been pumped in the last two years. System pumped as part of inspection: (yes or no)No If yes,volume pumped: 0 gallons . Reason for pumping: n1a TYPE OF SYSTEM X Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source information: 7130191 Sewage odors detected when arriving at the site: (yes or no) No (revised 11115195) 5 SUBSURFACE-SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART C SYSTEM INFORMATION(continued) Property Address: 95 Donegal Circle,Centerville - - Owner: -JEJ Reatlt9Trust Date of Inspection:WV96 SEPTIC TANK:X - (locate on site plan) Depth below grade: 16" Material of construction:x concreate_metal_FRP_other(explain) Dimensions: L 1o'8•H 5'7'W 4'10" Sludge depth:Z' Distance from top of sludge to bottom of outlet tee or baffle: 25' Scum thickness:o Distance from top of scum to top of outlet tee or baffle:6' _ Distance form bottom of scum to bottom of outlet tee or baffle: u Comments:, (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) Septic tank and all components are structurally sound.Recommend pumping system every two years for maintenance. GREASE TRAP: (locate on site plan) Depth below grade:Ida Material of construction: _concrete_metal_FRP_other(explain) Dimensions: nla. Scum thickness:n1a Distance from top of scum to top of outlet tee or baffle:n/a Distance from bottom of scum to bottom of outlet tee or baffle: nla Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) Na i (revised 111151" 6 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 95 Donegal Clrcle,Centerville _ Owner: JEJ Reality Trust - Date of Inspection:8122196..-_ TIGHT OR HOLDING TANK: - (locate on site plan) Depth below grade: nla Material of construction:_concrete_metal_FRP -other(explain)- Dimensions: rda .Capacity: nia gallons Design flow: nfa gallons/day Alarm level: nla Comments: i (condition of inlet tee, condition of alarm and floatswitches, etc.) Na DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert: Liquid le el with bottom of pipe. Comments: (note if level and distribution is equal,evidence of solids carryover, evidence of leakage into or out of box etc.) D-box is structurally sound PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no) comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) Na (revised 11115195) 7 C SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION(continued)_ Property Address: 95 Donegal Circle,Centerville _ Owner: JEJReality_,rust Date of Inspection:8127J96 - SOIL ABSORPTION SYSTEM (SAS):x - - _.___ (locate on site plan,if possible; excavation not required, but may be approximated by non-intrusive methods) .If not determinedto be present, explain: n1a - - — - Type _. _ leaching pits, number: 1,000 gallon leach leaching chambers, number:n1a leaching galleries, number: n1a leaching trenches, number, length: nla leaching fields, number, dimensions:nia overflow cesspool, number:nia Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) The leach pit is structurally sound and functioning property. CESSPOOLS:_ (locate on site plan) Number and configuration: n1a Depth-top of liquid to inlet invert: nia Depth of solids layer: nia Depth of scum layer: nia Dimensions of cesspool: n1a Materials of construction: nia Indication of groundwater: nia inflow(cesspool must be pumped as part of inspection) n1a Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) n1a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: nia. Depth of solids: nta Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PrivyComments r (revised 11115195) a>Jag - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 95 Donegal Circle,Centerville- Owner: JEJ Reality Trust Date of Inspection:9/22198 SKETCH OF SEWAGE DISPOSAL SYSTEM: . _ include-ties to at least two permanent references landmarks or benchmarks ~ locate all-wells within_100'. - _ D ,q A� 316 DEPTH TO GROUNDWATER Depth to'groundwater:12 feef method of determination or approximation: USGS Maps and charts. (revised 11115195) f ffi i 1 v l� TOWN OF BARNSTABLE L LOCATION Lo 1 �, �.g0ye4'ig 1 G`��cCQ SEWAGE VILLAGE GPw tfC�34 ASSESSOR'S MAP Sk LOT INSTALLER'S NAME & PHONE NO. J-T 06SCOI) 77 ! ' !O y d ,�3EPTIC TANK CAPACITY f DAD g�d `O�► S 1 EACHING FACILITY:(type) (Z4.c- I (size) O. OF BEDROOMS .3 PRIVATE WELL O PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No r - t N 'Z3 AO)